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Contents

1. UPDATE

In a post on the Global Fund website on 28 September 2018, Board Leadership welcomed the advisory review on governance conducted by the Office of the Inspector General and described some of the measures that have been taken since the Governance Action Plan was developed in response to the review.

2. NEWS

The Government of Rwanda and the Global Fund took the lead, in 2014, on an innovative approach to health financing with the aim to improve the efficiency of Rwanda’s fight against HIV. The ‘National Strategy Financing’ approach has proved to enhance grant effectiveness, deliver results, and offer “good value for money,” according to independent evaluators Euro Health Group. This success paves the way for other countries to adopt the model in additional pilots, if they meet the criteria.

3. NEWS

In August and October 2018, the Global Fund Board approved two HIV grants and three TB grants worth $28.1 million. The Board also approved matching funds requests for six components valued at $15.9 million. This article provides some details of the approved funding.

4. INTERVIEW

As Christoph Benn leaves the Global Fund, after 15 years of service as the head of External Relations, he reflects – in a conversation with Aidspan – on the history of the Global Fund’s resource mobilization function, the successes achieved and challenges faced, and on the establishment of the Global Fund Replenishment.

5. FEATURE

The annual consultative meeting of the Global Fund’s African Constituencies took place in Addis Ababa, Ethiopia in October, to discuss a range of issues that may be raised at the Global Fund’s 40th Board Meeting next week, including the pervasive and longstanding problem of implementers’ absorptive capacity. Representatives at the Addis Ababa meeting included all country constituencies, as well as representation from the Global Fund Board, the Secretariat and UNAIDS.

6. NEWS

The Global Fund Board has provided funding for some interventions from the Unfunded Quality Demand Register. The funding has been added to an existing malaria grant in Burundi and an existing TB grant in Philippines. This is the first set of interventions from a portfolio optimization exercise conducted by the Secretariat for the 2017–2019 allocation cycle. The additional resources come from funding designated by the Audit and Finance Committee as being available for portfolio optimization.

7. COMMENTARY

Aidspan Board member Dr. Jesse Boardman Bump reflects on allocation processes for funding and other resources, on the eve of the Global Fund’s 40th Board meeting, to be held in Geneva on 14–15 November 2018. Allocations is one of the topics expected to be discussed at the meeting, before the Global Fund institutes changes to its allocations policy in 2019.

8. OF INTEREST

This is the second in a series of short interviews by Friends of the Global Fight with the Global Fund’s Senior Disease Coordinators. In this Q&A, Friends spoke with Dr. Wandwalo, the Senior Disease Coordinator specializing in tuberculosis, about the opportunities to fight TB covered in Friends’ report, “At the Tipping Point: U.S. Leadership to End AIDS, Tuberculosis and Malaria”.

9. PRESS RELEASE

On October 11, 2018, a bipartisan group of 18 U.S. senators urged Secretary of State Mike Pompeo and the Administration to increase the United States’ pledge to the Global Fund to Fight AIDS, Tuberculosis and Malaria for 2020-2022. The U.S. pledged $4.3 billion for the last three-year funding cycle in 2016.

Global Fund Board approves another $28 million in grants from the 2017–2019 allocations

On 17 August 2018 and on 26 October 2018, the Global Fund Board approved two HIV grants and three TB grants worth $28.1 million. The Board also approved $15.9 million in matching funds requests for six components.

These were the 12th and 13th batches of approvals from the 2017–2019 allocations. The Board was acting on the recommendations of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC). Interventions totaling $7.5 million were added to the Unfunded Quality Demand (UQD) Register. Domestic commitments to the programs represented by the approved grants amounted to $520.1 million.

WAPCAS = West African Program to Combat AIDS and STI. ONFP = "Office National de la Famille et de la Population."

For the grant denominated in euros (Togo), a conversion rate of 1 euro = 1.1676 US dollars was used. (The matching funds for Togo were approved in August 2018.)

A few more to come

To date, the Board has approved 239 country grants, representing $9.28 billion of the $10.30 billion allocation, for 2017–2019.

In 2018, there were three windows for the submission of funding requests, as follows:

Window 4: 7 February (TRP review took place 19–29 March)

Window 5: 30 April (TRP review took place 3–11 June)

Window 6: 6 August (TRP review took place 9–21 September)

There were 26 country funding requests in Window 4, 20 in Window 5 and 18 in Window 6. There were also 19 multi-country requests in Window 5 and another ten in Window 6.

No further formal windows are scheduled. The Secretariat informed Aidspan that funding requests from nine components remain outstanding –– three iterations, two TB, two TB/HIV, one HIV and one malaria. Some of these will be reviewed remotely during the remainder of 2018 by the TRP. (The first remote “plenary” was scheduled for October 2018.) Two remote review submission dates are planned for 2019: 31 January and 30 April.

GAC comments on individual funding requests

In presenting its recommendations, the GAC also provided comments on the individual funding requests. Below, we provide a summary.

Comoros TB

The Comoros TB grant aims to contribute to reducing TB mortality by 75% and incidence by 50% by 2025 compared to 2015 levels. The main activities of the grant are as follows: geolocating TB cases; systematically and exhaustively investigating contacts; finalizing a national guide for diagnosis and pediatric TB; organizing transportation of sputum to the GeneXpert machines; increasing integration of the national TB and HIV programs; and effectively implementing the community-based strategy, which was revised in 2018 along the lines of the Engage-TB approach. (The WHO’s Engage-TB approach involves integrating community-based TB activities into the work of civil society organizations.)

“Geolocation” refers to the process of identifying the geographical location of a person or device by means of digital information processed via the internet.

With support from the Global Fund grant, the National TB and Leprosy program aims to increase TB notification by 6% a year, reaching a 90% treatment success rate by 2021.

According to the GAC, the Government of Comoros has made a commitment to contribute an additional €453,724 to support the national disease programs, thus meeting the minimum co-financing requirement. (Table 2 above, which is based on a table from the same GAC report, shows a lower amount.) The GAC noted, however, that the country is vulnerable to “macroeconomic volatilities” and health systems challenges. The Secretariat will continue to monitor the progress on co-financing.

The GAC said that the Secretariat will encourage the country to exceed the minimum commitment “especially in light of a reduced allocation across the three components.” The reference to reduced allocations presumably means that the final 2017–2019 allocation to Comoros was below what the allocation formula called for. The formula-derived amounts were subject to a series of adjustments, one of which was a reduction for components that were deemed to have been “over-allocated” prior to the introduction of the new funding model.

The TB grant is the first of Comoros’ three grants from the 2017–2019 allocation to be approved. The HIV and malaria grants are currently in grant-making. The TB grant is scheduled to run from 1 October 2018 to 30 September 2021. The other two grants will have different time frames.

The GAC report referred to the possibility of a unique TB, HIV and malaria grant for the 2020–2022 allocation period. The Senior Fund Portfolio Manager for the Southern and Eastern African Region in the Secretariat’s Grants Management Division, Osian Jones, explained to Aidspan that the possibility of moving towards a unique grant covering the three disease components was discussed at a Comoros CCM General Assembly meeting on 14 July 2018, which coincided with grant negotiations.

“Having a unique grant could help reduce management and administrative costs across the portfolio, thereby maximizing the resources allocated to programmatic activities,” Jones said.

Jones noted that all of the Comoros grants for the 2017–2019 allocation will now be managed by the national disease programs as principal recipients (PRs). “For the 2020–2022 allocation period,” Jones said, “the CCM may decide to submit a joint application with a unique PR if adequate management structures are in place and if this is relevant to the country context at that time.”

At its meeting in July 2018, the CCM said that it would work with the PRs, the Ministry of Health and the Global Fund country team to harmonize the grant cycles for the 2020–2022 allocation period, ideally synchronized to Comoros’ fiscal cycle (1 January to 31 December).

The GAC welcomed what it termed “the harmonization of RSSH activities across the three grants,” noting that this is designed to facilitate the transition towards a unique grant in the 2020–2022 allocation period. Jones explained that, currently, there is no stand-alone RSSH grant in the Comoros portfolio. However, he said, the current HIV grant (COM-H-DNLS), which ends on 30 June 2019, contains an RSSH component which represents more than half the grant’s budget (€2.6 million out of €4.5 million). This RSSH component supports certain cross-cutting activities and investments that are common to all three national disease programs, such as the strengthening of M&E, and procurement and supply management systems.

Jones said that given there will be no RSSH component in the grants funded through the 2017–2019 allocations, in a decision taken on 25 November 2017 the CCM requested all PRs to reserve 10% of the grant budgets towards RSSH activities. This represents a total of € 604,966 over three years.

In addition, Jones said, during grant negotiations, it was agreed that the CCM, the Ministry of Health and the PRs would work with technical and financial partners to define a common RSSH work plan to ensure the efficient and effective use of the funds reserved for RSSH in each of the grant budgets.

El Salvador TB

The El Salvador TB grant will have an implementation period of 1 January 2019 (approximately) to 31 December 2021. The current TB grant, funded from El Salvador’s 2014–2016 allocation, is a national strategy financing (NSF) pilot. NSF pilots involve using achievements against a small set of national strategic plan (NSP) outcomes or impact indicators as the basis for annual funding decisions and disbursements. (See article in this issue on NSF in Rwanda [add link].) El Salvador has chosen to continue using the NSF approach for its new grant. Adjustments have been made based on lessons learned from the pilot.

The TB grant will support the strengthening of prevention and comprehensive care of new TB cases. El Salvador has adopted a strategic approach for priority populations and families facing catastrophic costs as a result of TB, in line with the global End TB Strategy. Key priorities of the country’s NSP include the following:

Increasing TB detection, mainly among people in detention and other key populations;

Additionally, the NSP aims to strengthen the health information system and ensure data quality to monitor TB diagnostic and treatment outcomes.

The GAC noted that the Government of El Salvador has committed to contribute an additional $637,060 to the national TB program in the 2017–2019 allocation period, thus meeting the minimum co-financing requirement. These funds will be spent on additional treatment, on cartridges for the GeneXpert machines, on maintenance, and on monitoring and evaluation.

The GAC said that the NSF pilot had resulted in “increased country ownership of the national response and a focus on value for money and impact rather than input management.” The GAC said that continuation of the pilot is key to the sustainability of the TB response in El Salvador.

According to Global Fund projections, El Salvador’s TB and malaria components are expected to become ineligible for support from the Fund during the 2017–2019 allocation cycle as a result of the country being reclassified by the World Bank as upper-middle income; the country may receive transition funding for TB and malaria in 2020–2022.

The country’s updated NSP (2017–2021) calls for the development of a strategy for building a sustainable national TB response. It also calls for the risks of transitioning from Global Fund support to be addressed.

The fund portfolio manager for El Salvador, Carmen Gonzalez, provided Aidspan with a copy of the NSP. The plan identifies the main risks as the national economic crisis; low revenues from taxes; and changes in government around election time.

The NSP states that El Salvador will achieve a successful transition through the implementation of the following strategies: (a) Governance and leadership: Strengthen the regulatory framework for the response to TB; (b) Financing: Increase domestic financing for the response to TB; (c) Efficiency: Strengthen the efficient use of existing resources; and (d) Participation: Strengthen community participation in the response to tuberculosis.

Guatemala HIV

The HIV grant will focus on the following areas:

Comprehensive prevention programs for men who have sex with men (MSM), transgender people, sex workers and people in prison in prioritized areas, based on disease burden;

Treatment care and support, including improved access to viral load and CD4 counts, transition to dolutegravir in first-line regimens, and differentiated and decentralized HIV care; and

Strengthening the health management information systems (HMIS) to allow monitoring of continuum of care and identification of key populations.

The aim of the prevention programs is to improve targeting, improve the quality of the prevention package and increase HIV case finding.

These investments are designed to reach 90% of the estimated population in targeted municipalities by 2020: 36,120 MSM, 1,610 transgender people, 13,095 sex workers and 4,500 people in prison. The goal is to have 20,609 people on antiretroviral treatment by the same date.

The GAC said that the Government of Guatemala has committed to contribute an additional $113.3 million, which is above the minimum co-financing requirement, and which represents an increase of $23.0 million compared to the 2014–2016 allocation period. The government has committed to increase the amount spent on human resources for the HIV response by almost $3.0 million. The GAC is encouraging the government to increase its HIV investments in medicines and diagnostic commodities.

The GAC welcomed the government’s interest in developing a sustainability strategy. The Secretariat indicated that there have been discussions with country stakeholders, including other donors and partners, with respect to the scope of the sustainability strategy, technical assistance (TA) needs, and an overall roadmap for development of the strategy. The terms of reference for the TA, which will be funded from the strategic initiative on Sustainability, Transition and Efficiency, have been developed. The TA is currently ongoing.

The GAC observed that the recommendation of the TRP to strengthen interventions addressing gender-based violence against girls and women, including transgender women, is “still in the process of being resolved.” The Secretariat suggested that the country develop a plan to frame the proposed interventions and identify activities that will be supported by the grant, as well as the activities that remain without funding and that may be considered for financing in future through a reprogramming exercise. A small amount of funding has been ring-fenced to finance any required TA and any additional needs that might arise from this plan.

Romania TB

Romania’s TB grant is a transition grant. It was developed on the understanding that Romania is not expected to receive any more funding from the Global Fund after this allocation and that the necessary measures for a successful transition to domestic funding will be adopted during the implementation period of the grant.

The GAC said that the funding request was based on thorough in-country consultations which included the development of a transition work plan. The systemic changes in-country that will be required during the transition will be supported by strengthening the capacities of civil society organizations (CSOs) to work with local and central decision-making authorities to increase access to health care for vulnerable groups.

Reshaping the model of care from hospital-based to ambulatory and community services;

Improving treatment outcomes in the most vulnerable, underserved and at-risk populations by developing a community-based integrated model of services; and

Strengthening community responses, systems and commitment for disease control by widening the involvement of CSOs and other community stakeholders to better address the needs of key and vulnerable populations –– including through the development and roll-out of a social contracting model for CSOs.

The fund portfolio manager for Romania, Sandra Irbe, told Aidspan that the transition grant includes a component on piloting an integrated care center for 2,000 persons from vulnerable groups, particularly people who inject drugs. The care center was created through a joint partnership agreement involving the Ministry of Health, the Bucharest Municipality Health Department, relevant healthcare centers and NGOs involved in harm reduction.

The center will provide an array of services, including (among others) needle exchange; opioid substitution therapy; condoms; medical and psychological support; and food and beverages.

Irbe said that because the last Global Fund HIV grant in Romania ended in 2011, and because no harm reduction services were picked up by domestic or external funding –– except for small financing of these services in Bucharest through the Global Fund’s TB grants –– this partnership agreement can be seen as a major milestone in promoting domestic awareness about the importance of this intervention.

Irbe told Aidspan that the Bucharest Local Council has just recently approved the purchase of a building where the integrated care center will be located.

The Government of Romania has agreed to contribute an additional €810,594, thus meeting its co-financing requirement for 2017–2019.

The grant budget includes salary incentives for 20 specialists employed by the Ministry of Health (MOH). The GAC deemed that the incentives were justified because of the need to deliver significant systemic changes and progress on policy issues within a short period of time. The MOH will assume 100% of the costs of all staff no later than 1 January 2021. (The end date of the grant is 31 March 2021.)

Tunisia HIV

Tunisia’s HIV grant will emphasize civil society strengthening. The GAC said that “the contributions of civil society will be crucial in terms of promoting the new services offered and supporting marginalized populations in accessing quality and sustainable care.”

The main focus of the grant will be on the following:

Harmonizing prevention interventions aimed at key populations;

Improving care services by offering antiretroviral therapy (ART) through four new outpatient clinics at national people-living-with-HIV care centers; and

Strengthening biological and viral load monitoring for 2,500 people on ART (nearly 70% of the estimated number of people living with HIV by 2021).

According to the GAC, more than 60% of sex workers and MSM will receive a package of services tailored to the needs of these populations; and 75% of injecting drug users will benefit from harm reduction interventions such as sterile syringe distribution, prevention, condom use, testing and referral to health facilities.

The GAC said that the Government of Tunisia has committed to increasing funding for the national HIV program by 2% a year, which is sufficient to meet its co-financing requirement. However, the GAC added, Tunisia is facing significant macroeconomic and fiscal challenges. Consequently, the Secretariat will monitor the co-financing commitments, which include funding for government utilization of a proposed methodology for HIV expenditures for the 2018 fiscal year by 30 June 2019; and development of a work-plan for the implementation of a transition readiness assessment.

The GAC noted that although the minimum co-financing requirements were met, there were no current plans for domestic uptake or scaling up of key population activities. In this light, the proposed transition readiness assessment takes on added importance.

The GAC applauded Tunisia’s commitment to address human rights–related issues identified through the country’s baseline assessment as well as the upcoming national plan for a comprehensive program to remove human rights–related barriers to HIV services. (This was the focus of the $1million in matching funds that Tunisia was awarded.)

GAC comments on matching fund awards

For the matching funds awards related to the Ethiopia RSSH and Tanzania RSSH priority areas, and for one of the awards for Ghana HIV (human rights-­related barriers priority area), the matching funds conditions were met. For the other awards, exceptions were requested.

For the Ghana HIV award related to the key populations impact priority area, the applicant did not meet the allocation condition, as the country was unable to demonstrate an increase in investment for this priority area vis-à-vis its 2014-2016 allocation.

For Philippines HIV, Togo RSSH and Tunisia HIV priority areas, the applicants were not able to meet the 1:1 match condition. The 1:1 condition requires that funding within the 2017–2019 allocation invested in the strategic priority area be equal to, or more than, the matching funds requested.

“Based on TRP recommendations,” the GAC said, “and noting the operating environment as well as the potential catalytic effect / impact of the investments,” waivers to the conditions were approved for Ghana, Philippines, Togo and Tunisia.

For previous matching funds requests, the GAC has frequently granted waivers to the conditions. Countries that have had their allocations reduced because the components in question were deemed to have been over-allocated prior to the introduction of the new funding model have had trouble finding the fiscal space to devote sufficient funding to the priority area for which matching funds were requested. The Global Fund will likely revisit the matching funds conditions when it determines the allocation methodology for the 2020–2022 period.

Extensions approved

The GAC said that to prevent program disruptions during grant-making, six-month extensions were granted for four grants: Armenia HIV (two grants), Guatemala malaria and Elimination 8 (a multi-country initiative). In all cases except Guatemala malaria, some additional funding was awarded. This funding was taken from the 2017–2019 allocations for the applicants involved.

Additional approvals: Batches 10 and 11

Editor’s Note: Through GFO, Aidspan has endeavored to report on the funding approvals for all grants in the 2017–2019 allocation period. We missed two batches of grants (batches #10 and #11) when they were approved around May 2018. In the two tables below, we provide some information on these approvals.

For the grant denominated in euros (Côte d’Ivoire), a conversion rate of 1 euro = 1.168 US dollars was used.

Aidspan reported on the ninth batch of grant approvals here. That article contains links to the GFO articles on the first eight batches.

Most of the information for this article was taken from four Board Documents: GF-B39-ER03, GF-B39-ER06, GF-B39-ER08 and GF-B39-ER12, each titled “Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee” and each undated. These documents are not available on the Global Fund website.